Month: July 2025

Emilia Kowalczyk

Introduction

The IOWISZ health system investment assessment system, introduced in 2016, aims to rationalize investments in the Polish health sector by directing public and private funds where they best meet social needs. Fulfilling Mark Moore’s concept of public value, the system is based on transparent evaluation criteria that support the public mission, equitable distribution of resources, and benefits for patients. However, challenges such as the lack of linkage between a positive IOWISZ assessment and the National Health Fund contract and inequalities in access to investments between large and small facilities limit its effectiveness. This article analyzes how IOWISZ implements public value, identifies key issues, and proposes solutions to increase the system’s effectiveness.

The Problem

IOWISZ, the Health Sector Investment Application Assessment Tool, was introduced in 2016 in response to critical assessments of the effectiveness of public investments made, particularly under the 2007-2013 Community Cohesion Policy, which often served particular interests rather than the public interest. However, how can we distinguish public interest from private interests and ensure that particular ambitions do not overshadow public goals?

In his groundbreaking book, Creating Public Value: Strategic Management in Government (1995), Mark Moore introduced the concept of public value. It means equitably creating good for individuals and communities, responding to their needs, while respecting and recognizing the contribution of each individual. In the monograph, Recognizing Public Value (2013), Moore expanded on this idea, proposing, following the example of the Balanced Scorecard development method, a proven business model, the Public Value Scorecard, a tool for sustainable public management in the spirit of public value, taking into account the organization’s mission, fairness of action, and stakeholder satisfaction. In this approach, public value is the benefits and results delivered by public institutions in response to societal needs, consistent with their mission. The IOWISZ system is intended to fulfill this mission, but its effectiveness depends on factors not yet regulated and is therefore susceptible to political pressure and advocacy from various interest groups.

Theoretical Assumptions

Analyzing healthcare investment from the perspective of Moore’s Public Scorecard, the primary goal of the IOWISZ system is to organize healthcare investments and ensure rational and efficient spending of public funds in the context of the public mission, equitable distribution of resources, and benefits for patients and medical staff. The IOWISZ application takes all these perspectives into account. After submission, the Minister of Health and voivodes issue opinions on the investment’s advisability after consultation with the National Health Fund. A positive assessment indicates the project’s alignment with local healthcare needs in the spirit of Moore’s public value approach, while a negative assessment indicates a misalignment with healthcare policy priorities, health needs maps, and transformation plans.

This system is designed to counteract haphazard, unjustified investments by supporting the better allocation of public funds. In this approach, IOWISZ supports the creation of public value because investments are generally directed to those with genuine social need.

Operational Practice

The IOWISZ system operates under the provisions of the Act on Healthcare Services Financed from Public Funds and is supported by the Ministry of Health, provincial governors, and the National Health Fund (NFZ). The participation of stakeholders, such as the directors of the NFZ’s provincial branches, is intended to ensure social and political legitimacy. The evaluation criteria are based on publicly available documents, which increases transparency and public trust. However, it is worth emphasizing that a positive IOWISZ assessment does not guarantee a contract with the NFZ, as funding depends on additional factors such as budget, regional priorities, and the availability of resources. As Moore predicted, the agreed public value in the public health system must still be formally legitimized and supported by a contract with the NFZ. If a facility implements a costly investment based on a positive IOWISZ assessment but fails to secure funding, this can seriously threaten its financial stability, hinder its development, and reduce public trust. This indicates the need for better coordination between the IOWISZ assessment and the NFZ contracting process. The proposal to formally link a positive IOWISZ assessment to a contract promise with the National Health Fund (NFZ) has been repeatedly raised in the public domain, but has yet to receive legislative approval. As Robert Mołdach pointed out in a report commissioned by the European Commission, “External expertise on European Structural and Investment Funds Implementation in the healthcare sector in Poland” (2019), this would require increased decision-making power for the national payer, which, however, goes beyond current political consensus.

In practical terms, the IOWISZ system functions as an IT tool enabling the evaluation of applications according to precise point criteria (e.g., 6,200 points for investments expanding the scope of services). This process takes place within a clearly defined timeframe – the voivode has 45 days to issue an opinion.

However, the system also generates inequalities. Larger entities, with better financial and expert resources, can outsource the preparation of professional applications to consulting firms, increasing their chances of success. However, smaller facilities, especially those struggling financially, often lack the resources to prepare applications that meet stringent requirements. This leads to their rejection and, consequently, deepens inequalities in access to investment and healthcare.

Summary:

The IOWISZ system contributes to building public value by aligning investments with health-related goals.tne i kierując je zgodnie z potrzebami społeczeństwa. Jego mocne strony to transparentność, określone kryteria i automatyzacja. Wymaga jednak usprawnień:

• lepszej integracji z procesem kontraktowania w NFZ, aby uniknąć ryzyka niewykorzystania pozytywnie ocenionych inwestycji,
• wsparcia mniejszych świadczeniodawców, aby zmniejszyć nierówności w dostępie do środków i zwiększyć szanse na realizację potrzeb zdrowotnych w mniej uprzywilejowanych regionach.

Robert Mołdach

Reflections after the Public Value Agreement webinar

The webinar, organized on July 14th as part of the Public Value Alliance, focused on the role that the public value-based public management concept and method can play in reforming the healthcare system and public governance more broadly. This topic is of paramount importance given the challenges we face as a country and society.

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Public value as a axis of change in the health system

Robert Mołdach, PhD, presented a starting point. He pointed out that the discussion on health reform is taking place in conditions of weakened community and social capital. He drew on the reflections of Robert Putnam, who demonstrated how the breakdown of social bonds leads to the fragmentation of communities and, consequently, the ineffectiveness of public institutions, and on Mark H. Moore’s concept of public value. The latter, developed in response to the challenges of contemporary administration, is based on the assumption that the role of public leadership is not merely to implement policies but to create sustainable public value.

Moore’s strategic triangle model, encompassing the creation of public value, building legitimacy, and implementing capacity, was presented. It was emphasized that although this approach originated in the American context, its essence—linking the meaning of actions with their real feasibility and social mandate—remains universal. This remains particularly relevant in times of challenges and conflicts.

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From concept to practice – tools and approaches

Later in the meeting, Emilia Kowalczyk demonstrated how the strategic triangle can be used as a tool for planning and implementing changes in the healthcare system. Gabriela Moczeniat, PhD, EMBA, discussed the concept of public value accounting as a method for assessing actions in the context of social utility, and Agnieszka Dubiel introduced the concept of the public value chain – from political intention to actual outcomes experienced by citizens.

It was pointed out that viewing public value through the lens of public value allows us to transcend institutional and particularistic logic. It enables a more coherent approach to planning and evaluating reforms – regardless of who currently holds the decision-making role.

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How is the public value approach different?

One of the questions concerned what the public value approach brings to the table compared to existing public management methods used in Poland. Emilia Kowalczyk emphasized that the difference lies not only in the tools, but also in the starting point: it’s not about improving the effectiveness of institutions for their own sake, but about giving meaning to public actions by referencing socially recognized values. It is by aligning these values ​​that work on public policies should begin. Agnieszka Dubiel added that this requires a change in current practice and an understanding by public leaders of the public value chain based on real needs, social justice, and fairness.

It was emphasized that public value is neither a tool for optimization nor an economic category. It is a framework that allows us to understand who the system serves, what creates its legitimacy, and what resources are needed to maintain and develop this value.

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Voices from Practice: Accountability, Coherence, and Constraints

In an open discussion, superbly moderated by Tomasz Rowiński, PhD, EMBA, Agnieszka Dubiel spoke directly about staff burnout and internal tensions – and how change begins not with another regulation, but with a culture of collaboration. Magdalena Łasińska-Kowara highlighted the lack of distributed responsibility in the healthcare system and the need to think in terms of teams and collective outcomes. Gabriela Moczeniat, PhD, EMBA, emphasized the role of technical and information limitations that hinder the realization of the concept of public value, such as distributed IT systems and lack of interoperability. Łukasz Bruski cited the example of the decision of the deaf parents of a deaf child who opposed the implantation of a hearing-restoring implant for their child, fearing it would exclude the child from their community. He demonstrated that understanding public value requires sensitivity, dialogue, and consideration of individual identities and relationships, not just data and procedures. Dariusz Dziełak brought this discussion to a close by pointing out that a conversation about values ​​must begin before political deadlines and campaigns emerge. This is a task not only for politicians but also for professional, academic, and civic communities.

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Leadership Research and the Need to Talk About the Meaning of Reform

In the final section, one participant mentioned her research on the attitudes of leaders in primary care. Robert Mołdach, PhD, suggested that such research should also be extended to political decision-makers – for example, members of the Council of Ministers or the Chancellery of the Prime Minister – to understand their beliefs regarding public value and their willingness to think long-term about reform. The question, however, is whether they would be willing to undergo such research and share its results with the public?

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Conclusions and perspectives

The meeting confirmed that the concept of public value can be a starting point for a more sustainable, meaningful, and socially acceptable approach to changes in the healthcare system. Not as an alternative to efficiency, but as its complement – ​​organizing goals, defining meaning, and helping to build a common language in a fragmented system. It also creates conditions for the objective selection of state priorities and ensures effective implementation.

The next meeting of the Agreement for Public Value is planned for the Economic Forum in Karpacz, as part of the Fishbowl session, to which you are cordially invited.

p.s. Special thanks to Iga Lipska MD PhD MPH for inspiring this unique discussion format.